Englisch

Visit 16 Immunogenicity and reactogenicity of GlaxoSmithKline Biologicals' inactivated hepatitis A vaccine 100576

1 Formulare  
Informed Consent
Beschreibung

Informed Consent

Alias
UMLS CUI-1
C0021430
UMLS CUI-2
C0170300
Subject Number
Beschreibung

Subject Number

Datentyp

text

Alias
UMLS CUI [1]
C2348585
Center number
Beschreibung

Center number

Datentyp

text

Alias
UMLS CUI [1,1]
C1301943
UMLS CUI [1,2]
C0600091
Date of Visit
Beschreibung

Date of Visit

Datentyp

date

Alias
UMLS CUI [1]
C1320303
Informed Consent Date
Beschreibung

I certify that Informed Consent has been obtained prior to any study procedure.

Datentyp

time

Alias
UMLS CUI [1,1]
C0021430
UMLS CUI [1,2]
C0011008
Demographics
Beschreibung

Demographics

Alias
UMLS CUI-1
C0011298
UMLS CUI-2
C0170300
Subject Initials
Beschreibung

Subject Initials

Datentyp

text

Alias
UMLS CUI [1]
C2986440
Date of birth
Beschreibung

Date of birth

Datentyp

date

Alias
UMLS CUI [1]
C0421451
Gender
Beschreibung

Gender

Datentyp

text

Alias
UMLS CUI [1]
C0079399
Race
Beschreibung

Race

Datentyp

text

Alias
UMLS CUI [1]
C0034510
Race, if other please specify
Beschreibung

Race

Datentyp

text

Alias
UMLS CUI [1]
C0034510
Laboratory Tests
Beschreibung

Laboratory Tests

Alias
UMLS CUI-1
C0022885
UMLS CUI-2
C0005834
UMLS CUI-3
C0170300
Has a blood sample been taken for serology?
Beschreibung

blood sample

Datentyp

boolean

Alias
UMLS CUI [1]
C0005834
Has the subject received since the last visit: A dose of monovalent or combined Hepatitis A vaccine?
Beschreibung

Hepatitis A vaccine

Datentyp

boolean

Alias
UMLS CUI [1]
C0170300
Has the subject received since the last visit: A dose of Hepatitis A immunoglobulins within 6 months prior to bleeding?
Beschreibung

Hepatitis A immunoglobulins

Datentyp

boolean

Alias
UMLS CUI [1]
C3652495
Follow-up Studies
Beschreibung

Follow-up Studies

Alias
UMLS CUI-1
C0016441
UMLS CUI-2
C0170300
Would the subject be willing to participate in a follow-up study?
Beschreibung

follow-up study

Datentyp

boolean

Alias
UMLS CUI [1,1]
C0016441
UMLS CUI [1,2]
C2348568
reason for non participation
Beschreibung

If No, please specify the reason

Datentyp

integer

Alias
UMLS CUI [1,1]
C0558080
UMLS CUI [1,2]
C0679823
UMLS CUI [1,3]
C0392360
Reason for non participation: Adverse Events, or Serious Adverse Events, please specify
Beschreibung

reason for non participation

Datentyp

text

Alias
UMLS CUI [1]
C0877248
UMLS CUI [2,1]
C0558080
UMLS CUI [2,2]
C0679823
UMLS CUI [2,3]
C0392360
Reason for non participation: Other, please specify
Beschreibung

reason for non participation

Datentyp

text

Alias
UMLS CUI [1,1]
C0558080
UMLS CUI [1,2]
C0679823
UMLS CUI [1,3]
C0392360
Investigator Signature
Beschreibung

I certify that I have reviewed the data in this case report form, and the Serious Adverse Event section (if applicable) and that all information is complete and accurate.

Datentyp

text

Alias
UMLS CUI [1]
C2346576
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Ähnliche Modelle

Visit 16 Immunogenicity and reactogenicity of GlaxoSmithKline Biologicals' inactivated hepatitis A vaccine 100576

1 Formulare
Name
Typ
Description | Question | Decode (Coded Value)
Datentyp
Alias
Item Group
Informed Consent
C0021430 (UMLS CUI-1)
C0170300 (UMLS CUI-2)
Subject Number
Item
Subject Number
text
C2348585 (UMLS CUI [1])
Center number
Item
Center number
text
C1301943 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Date of Visit
Item
Date of Visit
date
C1320303 (UMLS CUI [1])
Informed Consent Date
Item
Informed Consent Date
time
C0021430 (UMLS CUI [1,1])
C0011008 (UMLS CUI [1,2])
Item Group
Demographics
C0011298 (UMLS CUI-1)
C0170300 (UMLS CUI-2)
Subject Initials
Item
Subject Initials
text
C2986440 (UMLS CUI [1])
Date of birth
Item
Date of birth
date
C0421451 (UMLS CUI [1])
Item
Gender
text
C0079399 (UMLS CUI [1])
Gender
Code List
Gender
CL Item
Male (M)
CL Item
Female (F)
Item
Race
text
C0034510 (UMLS CUI [1])
Race
Code List
Race
CL Item
White (WH)
CL Item
Black (BL)
CL Item
Oriental (OR)
CL Item
Other (OT)
Race
Item
Race, if other please specify
text
C0034510 (UMLS CUI [1])
Item Group
Laboratory Tests
C0022885 (UMLS CUI-1)
C0005834 (UMLS CUI-2)
C0170300 (UMLS CUI-3)
blood sample
Item
Has a blood sample been taken for serology?
boolean
C0005834 (UMLS CUI [1])
Hepatitis A vaccine
Item
Has the subject received since the last visit: A dose of monovalent or combined Hepatitis A vaccine?
boolean
C0170300 (UMLS CUI [1])
Hepatitis A immunoglobulins
Item
Has the subject received since the last visit: A dose of Hepatitis A immunoglobulins within 6 months prior to bleeding?
boolean
C3652495 (UMLS CUI [1])
Item Group
Follow-up Studies
C0016441 (UMLS CUI-1)
C0170300 (UMLS CUI-2)
follow-up study
Item
Would the subject be willing to participate in a follow-up study?
boolean
C0016441 (UMLS CUI [1,1])
C2348568 (UMLS CUI [1,2])
Item
reason for non participation
integer
C0558080 (UMLS CUI [1,1])
C0679823 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
reason for non participation
Code List
reason for non participation
CL Item
Adverse Events, or Serious Adverse Events (1)
CL Item
Other (2)
reason for non participation
Item
Reason for non participation: Adverse Events, or Serious Adverse Events, please specify
text
C0877248 (UMLS CUI [1])
C0558080 (UMLS CUI [2,1])
C0679823 (UMLS CUI [2,2])
C0392360 (UMLS CUI [2,3])
reason for non participation
Item
Reason for non participation: Other, please specify
text
C0558080 (UMLS CUI [1,1])
C0679823 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Investigator Signature
Item
Investigator Signature
text
C2346576 (UMLS CUI [1])
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